SBRT or LDR Brachytherapy Treatment Options for 54 Year Old w/GG2 Diagnosis

[Indy2012]

Recently diagnosed in late January 2021 and am exploring treatment options. I turn 54 in August, and my urologist is concerned with radiation therapy at my age. We’ve discussed HIFU and TULSA-PRO as a possible alternatives to RP or RT. Meeting with an RO yesterday to get his perspective on SBRT as it appears to be viable for me. The recommendation was LDR brachytherapy.

What are people hearing about RT (SBRT or Brachytherapy) as it relates to younger patients? Thanks!

My pathology results revealed a total of 3 of 13 cores positive for prostate adenocarcinoma, 2 of which were 3+3=6, 5% of core each, but one of these cores was 3+4=7, involving 15% of the core. Scheduled for a fusion biopsy next week.

Oncotype DX put me right in the middle of the risk assessment.

Underwent a 3T MRI in April at Indiana University Health in Indianapolis. The results are as follows:

The prostate gland is mildly enlarged and heterogeneous. Multiple well-circumscribed nodules within the transition zone are consistent with BPH. Few small intrinsic T1 hyperintense foci are noted consistent with postbiopsy hemorrhage. Heterogeneous decreased T2 signal throughout the peripheral zone which is indeterminant and could represent prostatitis.

Lesion 1:

Size: 0.9 x 0.7 x 0.9 cm

Side: Right

Position: Central

Location: Mid

Region: Lateral

Zone: Transition

ADC map ROI value: 745

Discrete enhancement: No

Extracapsular extension: EPE is not seen

Modified ACR PI-RADS CATEGORY: 3

Lesion 2:

Size: 1.8 x 1.3 x 1.5 cm

Side: Left

Position: Anterior

Location: Base and mid

Region: Lateral

Zone: Transition

ADC map ROI value: 741

Discrete enhancement: No

Extracapsular extension: EPE is not seen

Modified ACR PI-RADS CATEGORY: 3

Neurovascular bundle involvement: Not seen.

[Justfor_]

The doc that ordered/performed blind biopsy and then mpMRI is old school and you should find a more informed one. The reason: "postbiopsy hemorrhage" attenuating the detection capabilities of your mpMRI. If your forthcoming fusion biopsy doesn't change the scene radically, I think you should also consider active surveillance.

[Indy2012 in reply to Justfor_]

Agreed. That urologist was not with IU Health. I've moved on from him.

[Magnus1964]

You are a bit young to have brachytherapy. Once implanted those seeds can not removed. You can stop external beam radiation anytime if side effects warrant it.

[Mascouche in reply to Magnus1964]

Are you certain they cannot be removed? That would be cruel because it would mean he would have to stay away from young grandchildren and pregnant women forever.

[PCInPA in reply to Mascouche]

When I looked into this .. Low Does Brachy leaves the seeds in place but high does does not. Apparently, high dose has largely displaced low dose. I do not have a lot of details as I was not a good candidate. As others have said, you need to get to a center of excellence where you can meet with top notch surgeons and radiologists who work more as a team and will give you a more (not 100%) balanced perspective on your options.

[Tall_Allen in reply to Mascouche]

Not at all. The exterior radiation is negligible within a month.

[Mascouche in reply to Tall_Allen]

Good to know I had been misinformed. Staying away from grand kids would really suck.

[Magnus1964 in reply to Mascouche]

The external radiation from the seeds decreases over time.

[NYC_talker in reply to Magnus1964]

There is no harm re: LDR brachy and the seeds staying in place for life.

The radiation decays in 9 months, and during that time you are no danger to anyone. I have 66 seeds and the minimally-invasive procedure was one-and-done, out of the hospital in a few hours. The seeds will be in me for life and it's totally fine -- LDR is now used for many other types of cancer, in other parts of the body, on people of all ages.

It was a great option for me and others who are candidates. But you do need to have a smaller prostate, no or few urinary issues and cancer confined to the prostate.

Sometimes it can be done in combination with other therapies if needed. HDR brachy requires two treatments if done as monotherapy. If someone can do LDR as monotherapy I highly recommend it.

And the reason it's being done less, btw, is because it requires great skill by experienced practitioners and is reimbursed poorly by insurance companies and is administered in just one procedure (thus less to bill), even as it is actually more cost-effective than other treatments.

[ODave]

I was diagnosed at 55 in March last year. Pirads 5..5 cores out of 17 3+4-7 with high volume, one was over 60%. The Urologist wanted surgery, I consulted with 2 surgeons one at Sutter and one at UCSF and 2 RO’s one of the RO’s was at Loma Linda and the other at UCSF. I took months to choose, I went with SBRT at UCSF in Sept of 20. I know some think surgery is better at the younger age but I didn’t want all the initial side effects of surgery being younger.

[redonthehead]

I'm 59 and just finished my SBRT this morning. Back to work after each fraction. minor irritation but no big deal thus far. I was rated as favorable intermediate risk. There is very little to be found about long term risk of radiation for PCa causing other cancers.

IIRC the low dose seeds are only a short term risk for others.

[Tall_Allen]

I was 57 when treated with SBRT. But you may be giving up on AS too fast. The important stat is one you didn't supply: What % of the GS 3+4 is pattern 4? After you get your biopsy, have the cores sent to Epstein's Lab at Johns Hopkins for a second opinion. He will tell you the % pattern 4:

pathology.jhu.edu/patient-c...

Oncotype Dx seems not to be as good as Prolaris or Decipher:

ascopubs.org/doi/10.1200/JC...

TULSA-PRO is a really bad idea:

prostatecancer.news/2021/03...

Either SBRT or brachytherapy have very good outcomes for favorable intermediate risk patients:

prostatecancer.news/2018/10...

[Indy2012 in reply to Tall_Allen]

Agreed on AS. The plan is to use the results of the fusion biopsy next week to determine best treatment options or if AS is appropriate. Percentage of Grade 4 from the first biopsy was 5%.

Thanks for the info!

[Tall_Allen in reply to Indy2012]

5% is negligible, and should not necessarily justify treatment, according to most experts.

[Indy2012 in reply to Tall_Allen]

Hopefully, I'll have a clearer picture after the fusion biopsy. Thanks again!

[ODave in reply to Tall_Allen]

Tall_Allen is correct like usual, I forgot to mention I too sent my biopsy cores to Epstein for a 2nd opinion. They downgraded a few and found a little cribriform pattern in one.

[Canuck2020 in reply to Tall_Allen]

These are very good references T-A. Thanks for posting them. Low and intermediate risk patients take note. You need to know this.

[PCInPA]

The good news is that there is no need for you to to rush to a decision. All of the treatments options have their downsides. Your young age is a factor no matter what route you choose.

Use the time to explore what is right for you. Find a center of excellence where you can confer with multiple specialists. Be careful of biased opinions from any one specialty and be careful of falling into the trap of confirmation bias. Experience of the practitioner or equally or more important than the therapy but do not undervalue bedside manner.

Be wary of unproven technologies. There are many practices eager to take your money based on anecdotal evidence. Read Tall_Allen's excellent insights on TulsaPro.

Each case is unique so you can not take any one person's experience and expect to have the same outcome good or bad. One thing I have discovered is that people are willing to discuss the positive outcomes of their treatment but are more reluctant to acknowledge or share complications. I think this is human nature. It is a huge decision and there is no looking back once you have started. It is easier to convince yourself that you did the right thing than to focus on what went wrong and the possibility that you made the wrong decision.

Active surveillance may buy you time as procedures and options do improve continuously. That comes down to your personal risk tolerance as well your willingness to go through repeated biopsies and other tests. Active surveillance does not mean you do nothing.

No easy choices in this game.

[CHPA in reply to PCInPA]

And the other good news is you caught this very early. While it sucks, it sucks a lot less than if you were not doing routine testing and only found out in five or ten years when your options were fewer. You have time to research and weigh the options.

[TFBUNDY]

No rush, and don't panic. My diagnosis was worse than yours, but pirads 4 G 3+4. I decided on HIFU because it can be repeated, and it does not prevent future radiotherapy or surgery. So far so good. HIFU or TULSA Pro keeps all the other options open.

[cesces]

You can do both radiation AND brachytherapy.

I did.

[aceace12]

any specialist will recommends is specialty..... you sound like you need to stay on AS